| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not identify and manage its risks, such as organisation, storage conditions and management of medicines, appropriately. It cannot show that its written procedures are reviewed regularly. Or that team members are familiar with them. |
Have bought and starting to implement new set of standard operating procedures which all the relevant staff will need to read and sign. |
04/07/2019 | 01/07/2019 |
| 1.2 | The pharmacy cannot show how it records and learns from dispensing mistakes. |
Created Near miss logs and near miss summary forms which are to be stored in Current Operations Folder – To be regularly reviewed to minimise errors and learn from mistakes. Staff involved and others to be notified of near miss and errors and sign document to show confirmation and actions implemented, for example amitriptyline different strengths but same packaging have been separated with a divider. |
04/07/2019 | 01/07/2019 |
| 1.3 | Some members of the team are not clear about what they can or can't do in the absence of the responsible pharmacist. |
Responsible pharmacist SOP has been shown to all and list of dos and don’ts have been printed and left near the tills as a reminder. |
04/07/2019 | 01/07/2019 |
| 1.7 | The pharmacy doesn’t always manage or dispose of people’s private information properly. |
A shredding time has been made available twice during the day. Allocated baskets labelled confidential waste are to be kept out of patient view and shredded in the afternoon and at close of business. |
04/07/2019 | 01/07/2019 |
| 2.1 | The pharmacy does not have enough staff for its services. |
We have decided to place an advert in the window to see if we can recruit – if we do not have any luck we will have to place adverts online. |
04/07/2019 | 01/07/2019 |
| 2.2 | Some team members haven’t done the right training for the tasks they do. Such as selling pharmacy only medicines. |
Appraisals will begin as have invested in a HR support folder and from there will identify individual staff needs and place them on appropriate courses. All staff on the counter and selling medicines will be signed up to the appropriate course – contacted YJ at Avicenna |
04/07/2019 | 01/07/2019 |
| 3.1 | The pharmacy is disorganised and cluttered. And this could increase risks to people's safety. |
Re-organisation of dispensary and work flow has been looked at and new motto of clean and clutter free to help minimise risks. |
04/07/2019 | 01/07/2019 |
| 4.2 | The pharmacy doesn't always provide its services safely. It doesn’t always label multi-compartment compliance aids when they are assembled. Or store them appropriately. It doesn’t always provide the extra information people taking higher-risk medicines need to take them safely. |
Risk assessment to be completed taken from Health and safety folder. Re-educated all staff of labelling multi-compartment compliance aids and the safe storage of compliance aids to minimise mixing and risk to the patient. |
04/07/2019 | 01/07/2019 |
| 4.3 | The pharmacy doesn't always store medicines securely or appropriately. And it doesn't remove date-expired medicines promptly. It doesn’t always record the fridge temperatures regularly. This makes it harder to show that the medicines inside are still safe for people to use. |
New forms have now been created and to be used stored in Current Operations and then historically in another new folder termed Clinical Governance. |
04/07/2019 | 01/07/2019 |
Pharmacy inspections
Inspection reports and learning from inspections